Comprehensive Medical Review

Date:

Claimant Name - Last*: First*: Middle Initial:

*Insured's Name: *Policy #

Claim # : *

Date of Accident*:

Insurance or client name*:

Claims Examiners Name*:

Address*:

Insurance Co. Name:

Phone Number: Ext:

Due Date:

Type of Peer Review

Neurological

Psychiatric (MD)

Internal Medicine

Physiatrist(PMR)

Psychological (PHD)

Radiological

Chiropractic

Orthopedic

Other

Billing Information

Date of Service

Amount of Bill

Service Provider

Special Instructions (Please provide purpose of review: (medical necessity, etc.)

Has an I.M.E.(s) been previously requested? Yes No
Will you need to upload files with this request? Yes No